Sørensen et al. Int J Bipolar Disord (2017) 5:29 DOI 10.1186/s40345-017-0098-0
Open Access
RESEARCH
Sexual distress and quality of life among women with bipolar disorder Thea Sørensen1,2, A. Giraldi2,3 and M. Vinberg1,3*
Abstract Background: Information on the association between bipolar disorder (BD), sexual satisfaction, sexual function, sexual distress and quality of life (QoL) is sparse. This study aims, in women with BD, to (i) investigate sexual dysfunction, sexual distress, general sexual satisfaction and QoL; (ii) explore whether sexual distress was related to affective symptoms and (iii) investigate whether QoL was associated with sexual distress. The study is a questionnaire survey in an outpatient cohort of women with BD using: Changes in Sexual Functioning Questionnaire, Female Sexual Distress Scale, Altman Self-Rating Mania Scale (ASRM), Major Depression Inventory (MDI) and The World Health Organisation Quality of Life-Brief. Results: In total, 61 women (age range 19–63, mean 33.7 years) were recruited. Overall, 54% reported sexual distress (n = 33) and 39% were not satisfied with their sexual life (n = 24). Women with BD were significantly more sexually distressed in comparison with Danish women from the background population but they did not have a higher prevalence of impaired sexual function. Better sexual function was positively associated with ASRM scores while MDI scores were associated with more distress. Finally, the group of non-sexually distressed women with BD reported higher QoL scores compared with the sexually distressed group. Conclusions: Women with BD exhibited a high prevalence of sexual distress and their sexual function seemed associated with their actual mood symptoms and perception of QoL. Keywords: Sexual distress, Sexual functioning, Quality of life, Bipolar disorder Background Sexual dysfunction is defined as an impaired sexual function that causes distress. The definition has changed several times over the course of time but a division into four categories overall has remained: desire/interest, arousal, orgasm and pain disorders (Basson et al. 2000, 2004, 2010; McCabe et al. 2016). Sexual dysfunction is caused by biological, psychological and social interactions and factors with negative influence on human well-being. Additionally, the risk of sexual dysfunction is increased by factors such as socio-economic status (Christensen et al. 2011a), psychiatric disorders (Brotto et al. 2011), partner status and the length of relationship (Hayes et al. *Correspondence: [email protected] 1 Copenhagen Affective Disorder Clinic, Psychiatric Centre Copenhagen, Copenhagen University Hospital, Rigshospitalet, Dep. 6233, Blegdamsvej 9, 2100 Copenhagen, Denmark Full list of author information is available at the end of the article
2008; Eplov et al. 2007), menopause (Ornat et al. 2013) and the side effects of psychotropic treatment (Bergh and Giraldi 2014; Serretti and Chiesa 2011a; Zemishlany and Weizman 2008). A Danish study (n = 4415) concluded that mental health problems and poor self-rated health problems were strongly associated with female sexual dysfunction (Christensen et al. 2011b). Information on the association between bipolar disorder, quality of life, sexual satisfaction, sexual function and distress is sparse. It is well known that depression and antidepressants affect sexual function negatively (Clayton et al. 2014), but only a few studies include women with BD. Besides, the studies have small study populations and different questionnaires, none of which include sexual distress (Dell’Osso et al. 2009; Ghadirian et al. 1992; Grover et al. 2014). In an Italian study (Dell’Osso et al. 2009) comparing 142 patients (60 with BD and 82 with unipolar depression) with 101 healthy controls, patients
© The Author(s) 2017. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.
Sørensen et al. Int J Bipolar Disord (2017) 5:29
with BD reported more sexual dysfunction compared to healthy control persons. Patients with BD had increased sexual desire in comparison with patients with unipolar disorder in the Italian study. Also, the presence of periods characterised by frequent sexual partners was significantly associated with the feeling that life is not worth living and sexual dysfunction was associated with lifetime suicide attempts. Finally, a Dutch study in the general population of the Netherlands showed an association between BD and sexual dissatisfaction (Vanwesenbeeck et al. 2014). Episodes of depression or mania can be trigged by stress. Patients with BD are probably more easily distressed, and therefore, sexual distress could be a potential trigger for depression and/or mania. The possible relationship between sexual distress and affective symptoms in patients with BD has not been evaluated previously. Further, quality of life (QoL), the general well-being and observed life satisfaction in many aspects—for example, physical and psychological health, education, employment, wealth, finance, environment, social relations and sexual function—are important aspects of QoL. Patients with affective disorders have a lower score of QoL compared to the general population (Nørholm 2008; Yatham et al. 2004; Nørholm and Bech 2001). When measuring QoL, according to World Health Organisation, sexual satisfaction is included as part of the total score (WHOQOL Group 1998). To improve treatment and QoL clinically in patients with BD, it is thus important to also focus on and include sexual function. The aim of the present study was, in a cohort of women with BD, to (i) investigate sexual function, sexual distress, general sexual satisfaction and QoL; (ii) explore whether sexual distress was related to affective symptoms and (iii) investigate whether QoL was associated to sexual distress.
Methods Study design
Women with BD were recruited to the questionnaire survey from the waiting room at the Copenhagen Affective Disorder Clinic, Psychiatric Centre Copenhagen. The included sample was derived from 1 March to 9 May 2015 from patients attending a region-wide secondary service for patients with primary bipolar disorders. The patients received written and oral information about the project before deciding whether to participate. Further, at the time the questionnaire was answered and diagnosis confirmed, medication was assessed from the patients’ medical records. The self-assessment questionnaire included parameters, among others, previously shown to affect sexual function: basic demographic information (age, education,
Page 2 of 9
civil status, sexual orientation, length of relationship, employment and information about children) and lifestyle (alcohol, smoking and weight). The other part of the questionnaire included is described below. Participants
The inclusion criteria were as follows: being women with a clinical diagnosis of BD, aged 18–70 years, reading and understanding Danish and willing to participate in the study. Participants were included in analyses independent of their answers, sexual preference, civil status, age and sexual activity. They were excluded from analysis when not diagnosed with BD according to their electronic hospital records. The control group consisted of a group of Danish women from a previous study conducted by our group (Giraldi et al. 2015) describing sexual function. In summary, these data were collected from a cross-sectional study of a large, broadly sampled, non-clinical population cohort of Danish women (573 women participated). They were drawn randomly from the Danish Central National Register and invited to participate by letter. The Danish women were included if they were sexually active with a partner within the 4 weeks prior (n = 429). As the control group had a significant higher mean age, we conducted an age-matched analysis between women with BD and a subsample of age-matched women from the control group (n = 122). Sexual function
The Female Sexual Function Index (FSFI) and Female Sexual Distress Scale (FSDS) were used to describe sexual function among the Danish women in the background population. They were categorised as having female sexual dysfunction (FSD) when FSFI score was ≤26.55 (impaired sexual function) and FSDS score ≥15 (Giraldi et al. 2015). In the present cohort, female sexual dysfunction was defined as a CSFQ-14 score ≤41 (impaired sexual function) and FSDS score ≥15 (distress). Questionnaires WHOQoL‑BREF, Quality of Life measure
Quality of life was assessed using an abbreviated version of the World Health Organisation Quality of Life Assessment brief version, WHOQoL-BREF (WHOQOL Group 1998), Danish version. The WHOQoL-BREF is a 26-item questionnaire developed from the original 100item questionnaire the WHOQoL-100. The WHOQoLBREF covers four different subscales (WHOQoL Group 1998): physical health (energy and fatigue, pain and discomfort, sleep and rest), psychological health (bodily image and appearance, negative feelings, positive
Sørensen et al. Int J Bipolar Disord (2017) 5:29
feelings, self-esteem, thinking, learning, memory and concentration), social relationships (personal relationships, social support and sexual activity) and environment (e.g. financial resources, freedom, physical safety and security, health and social care). Besides, one global item scores overall quality of life (overall QoL) and one global item scores general health. Each individual item of the WHOQoL-BREF is scored from one to five on a response scale. The scores are then transformed linearly to a 0–100 scale except items one and two, overall QoL and general health which are displayed in raw scores 1–5 (Noerholm et al. 2004). Higher scores indicate better QoL. The internal consistency of the Danish WHOQoLBREF was, in a pilot study, found to be psychometrically valid (Nørholm and Bech 2001). Finally, satisfaction with sexual life was assessed from item 21 (WHOQoL-BREF, “How satisfied are you with your sexual life?”) and categorised as unsatisfied when answered as “very unsatisfied” or “unsatisfied”. Altman Self‑Rating Mania Scale (ASRM)
Manic symptom scale scores were assessed by a short 5-item questionnaire that covered the symptoms of positive mood, self-confidence, sleep patterns, speech patterns/amount and motor activity. Each item is scored from 0 to 4 and depends on how the participants described their symptoms over the past week. Scores above five are indicative of mania or hypomania with the severity of symptoms increasing with higher scores (Altman et al. 1997). Major (ICD‑10) Depression Inventory (MDI)
Depression was measured by a 10-item questionnaire developed to measure DSM-IV and ICD-10 diagnoses of moderate to severe depression by self-reported symptoms during the past 2 weeks. The first three items cover the core symptoms of depression according to ICD-10 (depressed mood, lack of interest and lack of energy) while the other items cover the accompanying symptoms (lack of self-confidence, self-blame or guilt, thoughts of death or suicide, difficulty thinking and concentrating, agitation or inhibition, sleep disturbances and appetite and weight change). Each item has a possible score between 0 and 5 (0 = at no time, 5 = all the time). Items 8 and 10 were divided into two sub-items and only the highest scores of these items were included in the analysis. The theoretical score was 50 with a range from 0 (no depression) to 50 (major depression) and a higher score indicating the severity of depression. Cut-off scores ≥26 indicate moderate to severe depression. The internal and external validity were found to be psychometrically valid in two Danish studies (Bech et al. 2001; Olsen et al. 2003).
Page 3 of 9
Changes in Sexual Functioning Questionnaire‑14 (CSFQ‑14)
Sexual function was assessed by a questionnaire containing 14 questions with a total cut-off score ≤41 indicating impaired sexual function. Each item is scored in a 5-point scale that refers either to frequency (“never” to “every day”) or to satisfaction (“none” to “great”). The first item scores overall pleasure with present sexual life and the other items cover five subscales (sexual pleasure, sexual desire/frequencies, sexual desire/interest, arousal/ excitement and orgasm), and two items (10 + 14) about loss of arousal and painful orgasm (de Boer et al. 2014; Keller et al. 2006). CSFQ-14 has been validated to assess sexual dysfunction among patients taking antipsychotics and also covers all stages of sexual functioning compared to other questionnaires (de Boer et al. 2014). A score ≤41 is seen as an impaired sexual function and thus indicates sexual dysfunction (Keller et al. 2006). Female Sexual Distress Scale (FSDS)
Sexual distress was assessed by a 12-item questionnaire that covers the intensity and frequency of sexual distress the past 30 days. Each item scores from 0 to 4 (0 = never and 4 = always). A cut-off score ≥15 indicates sexual distress. FSDS has been validated in studies, including a pilot study with 60 healthy women and 18 women with different kinds of sexual dysfunction. It was concluded that the questionnaire is able to distinguish between those with and without sexual dysfunction and the study showed moderate positive correlation to general mental distress, and thus seems to be a good estimate of sexual distress (Derogatis et al. 2002). Ethical statement
Written informed consent was obtained from all participants. The study was approved by the Danish Data Protection Agency, Journal Number: 03568 and ID-Number: RHP-2015-004. Statistical analysis
All analyses were conducted using the Statistical Package for Social Sciences (version 22.0). Spearman’s correlation coefficients were used to test the associations between the variables (data measured from an ordinal scale). Chi square tests were used to compare variables within two groups and prevalence values between two groups. The study population (women patients with BD), Danish women from the background population as well as the age-matched controls were, separately, dichotomised into two groups: sexually distressed or not sexually distressed. An independent t test was used to compare mean scores and standard deviations. To investigate whether MDI scores or WHOQoL subscales were predictive of sexual distress, binary logistic
Sørensen et al. Int J Bipolar Disord (2017) 5:29
regression analyses including age and depression score according to MDI and the five WHOQoL subscales (general health, physical health, psychological health, social relationships and environment), were conducted, respectively. Finally, we compared information on sexual function among women with BD with data from women from the Danish background population and age-matched controls from this group, respectively.
Results
Page 4 of 9
Table 1 Demographic data and background characteristics of women with BD, N = 61, standard deviation I brackets Age (range 19–63 years) No training
38 (62%)
Other
16 (26%) 19 (31%)
Sexual orientation Heterosexual
50 (82%)
Homosexual/bisexual
11 (18%)
Civil status Single Married
28 (46%) 7 (11%)
Cohabiting with partner
11 (18%)
In a relationship, but live apart
15 (25%)
Children
23 (38%)
Children living at home
18 (30%)
Current smoker
21 (34%)
Menopause Body mass index (BMI = kg/m2); mean ± SD BMI 25 (overweight to obesity)
31 (51%)
Medication Antidepressants
8a (13%)
Antipsychotics
35 (57%)
Sleeping pills/benzodiazepines
24 (39%)
Mood stabilisers/lithium
50 (82%)
No medication
4 (7%)
Affective symptoms ASRM MDI In remission
10 (16%) 20b (33%) 31 (51%)
WHOQoL-BREF; mean ± SD Overall QoL
Impaired sexual function, sexual distress and general sexual satisfaction—prevalence, mean scores and correlation to affective symptoms
As seen from Table 2, 21 (34.4%) women with BD reported impaired sexual function (CSFQ-14 score ≤41). However, six patients were not distressed by this resulting in 15 (24.6%) out of 21 patients having a sexual dysfunction (impaired sexual function combined with sexual distress). Thirty-three (54.1%) women with BD had sexual distress. More than one-third was unsatisfied (answering “very unsatisfied” or “unsatisfied” to the question “How satisfied are you with your sexual life?”) with their sexual life. The study population had a mean score ± SD of
7 (12%)
Higher education Employed
Study characteristics
In total, 85 women were asked to participate; 14 did not answer the questionnaires (response rate 83.5%), eight were not diagnosed with BD and a further two did not fully complete the questionnaires, thus leaving 61 participants (72% included). As seen from Table 1, the participants were characterised by being young, single without children, heterosexual, well-educated and unemployed. The majority were non-smokers and overweight to obese (BMI > 25). Almost all were prescribed medication, especially mood stabilisers (mean number of medication: 2.2), and half were in remission. Women with BD and BMI > 25 were not prescribed more types of medication (mean 2.1) than those with BMI 5. Major Depression Inventory (MDI) number of patients with current depression defined as a score ≥26 (moderate/ severe). Remission defined as ASRM scores
Open Access
RESEARCH
Sexual distress and quality of life among women with bipolar disorder Thea Sørensen1,2, A. Giraldi2,3 and M. Vinberg1,3*
Abstract Background: Information on the association between bipolar disorder (BD), sexual satisfaction, sexual function, sexual distress and quality of life (QoL) is sparse. This study aims, in women with BD, to (i) investigate sexual dysfunction, sexual distress, general sexual satisfaction and QoL; (ii) explore whether sexual distress was related to affective symptoms and (iii) investigate whether QoL was associated with sexual distress. The study is a questionnaire survey in an outpatient cohort of women with BD using: Changes in Sexual Functioning Questionnaire, Female Sexual Distress Scale, Altman Self-Rating Mania Scale (ASRM), Major Depression Inventory (MDI) and The World Health Organisation Quality of Life-Brief. Results: In total, 61 women (age range 19–63, mean 33.7 years) were recruited. Overall, 54% reported sexual distress (n = 33) and 39% were not satisfied with their sexual life (n = 24). Women with BD were significantly more sexually distressed in comparison with Danish women from the background population but they did not have a higher prevalence of impaired sexual function. Better sexual function was positively associated with ASRM scores while MDI scores were associated with more distress. Finally, the group of non-sexually distressed women with BD reported higher QoL scores compared with the sexually distressed group. Conclusions: Women with BD exhibited a high prevalence of sexual distress and their sexual function seemed associated with their actual mood symptoms and perception of QoL. Keywords: Sexual distress, Sexual functioning, Quality of life, Bipolar disorder Background Sexual dysfunction is defined as an impaired sexual function that causes distress. The definition has changed several times over the course of time but a division into four categories overall has remained: desire/interest, arousal, orgasm and pain disorders (Basson et al. 2000, 2004, 2010; McCabe et al. 2016). Sexual dysfunction is caused by biological, psychological and social interactions and factors with negative influence on human well-being. Additionally, the risk of sexual dysfunction is increased by factors such as socio-economic status (Christensen et al. 2011a), psychiatric disorders (Brotto et al. 2011), partner status and the length of relationship (Hayes et al. *Correspondence: [email protected] 1 Copenhagen Affective Disorder Clinic, Psychiatric Centre Copenhagen, Copenhagen University Hospital, Rigshospitalet, Dep. 6233, Blegdamsvej 9, 2100 Copenhagen, Denmark Full list of author information is available at the end of the article
2008; Eplov et al. 2007), menopause (Ornat et al. 2013) and the side effects of psychotropic treatment (Bergh and Giraldi 2014; Serretti and Chiesa 2011a; Zemishlany and Weizman 2008). A Danish study (n = 4415) concluded that mental health problems and poor self-rated health problems were strongly associated with female sexual dysfunction (Christensen et al. 2011b). Information on the association between bipolar disorder, quality of life, sexual satisfaction, sexual function and distress is sparse. It is well known that depression and antidepressants affect sexual function negatively (Clayton et al. 2014), but only a few studies include women with BD. Besides, the studies have small study populations and different questionnaires, none of which include sexual distress (Dell’Osso et al. 2009; Ghadirian et al. 1992; Grover et al. 2014). In an Italian study (Dell’Osso et al. 2009) comparing 142 patients (60 with BD and 82 with unipolar depression) with 101 healthy controls, patients
© The Author(s) 2017. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.
Sørensen et al. Int J Bipolar Disord (2017) 5:29
with BD reported more sexual dysfunction compared to healthy control persons. Patients with BD had increased sexual desire in comparison with patients with unipolar disorder in the Italian study. Also, the presence of periods characterised by frequent sexual partners was significantly associated with the feeling that life is not worth living and sexual dysfunction was associated with lifetime suicide attempts. Finally, a Dutch study in the general population of the Netherlands showed an association between BD and sexual dissatisfaction (Vanwesenbeeck et al. 2014). Episodes of depression or mania can be trigged by stress. Patients with BD are probably more easily distressed, and therefore, sexual distress could be a potential trigger for depression and/or mania. The possible relationship between sexual distress and affective symptoms in patients with BD has not been evaluated previously. Further, quality of life (QoL), the general well-being and observed life satisfaction in many aspects—for example, physical and psychological health, education, employment, wealth, finance, environment, social relations and sexual function—are important aspects of QoL. Patients with affective disorders have a lower score of QoL compared to the general population (Nørholm 2008; Yatham et al. 2004; Nørholm and Bech 2001). When measuring QoL, according to World Health Organisation, sexual satisfaction is included as part of the total score (WHOQOL Group 1998). To improve treatment and QoL clinically in patients with BD, it is thus important to also focus on and include sexual function. The aim of the present study was, in a cohort of women with BD, to (i) investigate sexual function, sexual distress, general sexual satisfaction and QoL; (ii) explore whether sexual distress was related to affective symptoms and (iii) investigate whether QoL was associated to sexual distress.
Methods Study design
Women with BD were recruited to the questionnaire survey from the waiting room at the Copenhagen Affective Disorder Clinic, Psychiatric Centre Copenhagen. The included sample was derived from 1 March to 9 May 2015 from patients attending a region-wide secondary service for patients with primary bipolar disorders. The patients received written and oral information about the project before deciding whether to participate. Further, at the time the questionnaire was answered and diagnosis confirmed, medication was assessed from the patients’ medical records. The self-assessment questionnaire included parameters, among others, previously shown to affect sexual function: basic demographic information (age, education,
Page 2 of 9
civil status, sexual orientation, length of relationship, employment and information about children) and lifestyle (alcohol, smoking and weight). The other part of the questionnaire included is described below. Participants
The inclusion criteria were as follows: being women with a clinical diagnosis of BD, aged 18–70 years, reading and understanding Danish and willing to participate in the study. Participants were included in analyses independent of their answers, sexual preference, civil status, age and sexual activity. They were excluded from analysis when not diagnosed with BD according to their electronic hospital records. The control group consisted of a group of Danish women from a previous study conducted by our group (Giraldi et al. 2015) describing sexual function. In summary, these data were collected from a cross-sectional study of a large, broadly sampled, non-clinical population cohort of Danish women (573 women participated). They were drawn randomly from the Danish Central National Register and invited to participate by letter. The Danish women were included if they were sexually active with a partner within the 4 weeks prior (n = 429). As the control group had a significant higher mean age, we conducted an age-matched analysis between women with BD and a subsample of age-matched women from the control group (n = 122). Sexual function
The Female Sexual Function Index (FSFI) and Female Sexual Distress Scale (FSDS) were used to describe sexual function among the Danish women in the background population. They were categorised as having female sexual dysfunction (FSD) when FSFI score was ≤26.55 (impaired sexual function) and FSDS score ≥15 (Giraldi et al. 2015). In the present cohort, female sexual dysfunction was defined as a CSFQ-14 score ≤41 (impaired sexual function) and FSDS score ≥15 (distress). Questionnaires WHOQoL‑BREF, Quality of Life measure
Quality of life was assessed using an abbreviated version of the World Health Organisation Quality of Life Assessment brief version, WHOQoL-BREF (WHOQOL Group 1998), Danish version. The WHOQoL-BREF is a 26-item questionnaire developed from the original 100item questionnaire the WHOQoL-100. The WHOQoLBREF covers four different subscales (WHOQoL Group 1998): physical health (energy and fatigue, pain and discomfort, sleep and rest), psychological health (bodily image and appearance, negative feelings, positive
Sørensen et al. Int J Bipolar Disord (2017) 5:29
feelings, self-esteem, thinking, learning, memory and concentration), social relationships (personal relationships, social support and sexual activity) and environment (e.g. financial resources, freedom, physical safety and security, health and social care). Besides, one global item scores overall quality of life (overall QoL) and one global item scores general health. Each individual item of the WHOQoL-BREF is scored from one to five on a response scale. The scores are then transformed linearly to a 0–100 scale except items one and two, overall QoL and general health which are displayed in raw scores 1–5 (Noerholm et al. 2004). Higher scores indicate better QoL. The internal consistency of the Danish WHOQoLBREF was, in a pilot study, found to be psychometrically valid (Nørholm and Bech 2001). Finally, satisfaction with sexual life was assessed from item 21 (WHOQoL-BREF, “How satisfied are you with your sexual life?”) and categorised as unsatisfied when answered as “very unsatisfied” or “unsatisfied”. Altman Self‑Rating Mania Scale (ASRM)
Manic symptom scale scores were assessed by a short 5-item questionnaire that covered the symptoms of positive mood, self-confidence, sleep patterns, speech patterns/amount and motor activity. Each item is scored from 0 to 4 and depends on how the participants described their symptoms over the past week. Scores above five are indicative of mania or hypomania with the severity of symptoms increasing with higher scores (Altman et al. 1997). Major (ICD‑10) Depression Inventory (MDI)
Depression was measured by a 10-item questionnaire developed to measure DSM-IV and ICD-10 diagnoses of moderate to severe depression by self-reported symptoms during the past 2 weeks. The first three items cover the core symptoms of depression according to ICD-10 (depressed mood, lack of interest and lack of energy) while the other items cover the accompanying symptoms (lack of self-confidence, self-blame or guilt, thoughts of death or suicide, difficulty thinking and concentrating, agitation or inhibition, sleep disturbances and appetite and weight change). Each item has a possible score between 0 and 5 (0 = at no time, 5 = all the time). Items 8 and 10 were divided into two sub-items and only the highest scores of these items were included in the analysis. The theoretical score was 50 with a range from 0 (no depression) to 50 (major depression) and a higher score indicating the severity of depression. Cut-off scores ≥26 indicate moderate to severe depression. The internal and external validity were found to be psychometrically valid in two Danish studies (Bech et al. 2001; Olsen et al. 2003).
Page 3 of 9
Changes in Sexual Functioning Questionnaire‑14 (CSFQ‑14)
Sexual function was assessed by a questionnaire containing 14 questions with a total cut-off score ≤41 indicating impaired sexual function. Each item is scored in a 5-point scale that refers either to frequency (“never” to “every day”) or to satisfaction (“none” to “great”). The first item scores overall pleasure with present sexual life and the other items cover five subscales (sexual pleasure, sexual desire/frequencies, sexual desire/interest, arousal/ excitement and orgasm), and two items (10 + 14) about loss of arousal and painful orgasm (de Boer et al. 2014; Keller et al. 2006). CSFQ-14 has been validated to assess sexual dysfunction among patients taking antipsychotics and also covers all stages of sexual functioning compared to other questionnaires (de Boer et al. 2014). A score ≤41 is seen as an impaired sexual function and thus indicates sexual dysfunction (Keller et al. 2006). Female Sexual Distress Scale (FSDS)
Sexual distress was assessed by a 12-item questionnaire that covers the intensity and frequency of sexual distress the past 30 days. Each item scores from 0 to 4 (0 = never and 4 = always). A cut-off score ≥15 indicates sexual distress. FSDS has been validated in studies, including a pilot study with 60 healthy women and 18 women with different kinds of sexual dysfunction. It was concluded that the questionnaire is able to distinguish between those with and without sexual dysfunction and the study showed moderate positive correlation to general mental distress, and thus seems to be a good estimate of sexual distress (Derogatis et al. 2002). Ethical statement
Written informed consent was obtained from all participants. The study was approved by the Danish Data Protection Agency, Journal Number: 03568 and ID-Number: RHP-2015-004. Statistical analysis
All analyses were conducted using the Statistical Package for Social Sciences (version 22.0). Spearman’s correlation coefficients were used to test the associations between the variables (data measured from an ordinal scale). Chi square tests were used to compare variables within two groups and prevalence values between two groups. The study population (women patients with BD), Danish women from the background population as well as the age-matched controls were, separately, dichotomised into two groups: sexually distressed or not sexually distressed. An independent t test was used to compare mean scores and standard deviations. To investigate whether MDI scores or WHOQoL subscales were predictive of sexual distress, binary logistic
Sørensen et al. Int J Bipolar Disord (2017) 5:29
regression analyses including age and depression score according to MDI and the five WHOQoL subscales (general health, physical health, psychological health, social relationships and environment), were conducted, respectively. Finally, we compared information on sexual function among women with BD with data from women from the Danish background population and age-matched controls from this group, respectively.
Results
Page 4 of 9
Table 1 Demographic data and background characteristics of women with BD, N = 61, standard deviation I brackets Age (range 19–63 years) No training
38 (62%)
Other
16 (26%) 19 (31%)
Sexual orientation Heterosexual
50 (82%)
Homosexual/bisexual
11 (18%)
Civil status Single Married
28 (46%) 7 (11%)
Cohabiting with partner
11 (18%)
In a relationship, but live apart
15 (25%)
Children
23 (38%)
Children living at home
18 (30%)
Current smoker
21 (34%)
Menopause Body mass index (BMI = kg/m2); mean ± SD BMI 25 (overweight to obesity)
31 (51%)
Medication Antidepressants
8a (13%)
Antipsychotics
35 (57%)
Sleeping pills/benzodiazepines
24 (39%)
Mood stabilisers/lithium
50 (82%)
No medication
4 (7%)
Affective symptoms ASRM MDI In remission
10 (16%) 20b (33%) 31 (51%)
WHOQoL-BREF; mean ± SD Overall QoL
Impaired sexual function, sexual distress and general sexual satisfaction—prevalence, mean scores and correlation to affective symptoms
As seen from Table 2, 21 (34.4%) women with BD reported impaired sexual function (CSFQ-14 score ≤41). However, six patients were not distressed by this resulting in 15 (24.6%) out of 21 patients having a sexual dysfunction (impaired sexual function combined with sexual distress). Thirty-three (54.1%) women with BD had sexual distress. More than one-third was unsatisfied (answering “very unsatisfied” or “unsatisfied” to the question “How satisfied are you with your sexual life?”) with their sexual life. The study population had a mean score ± SD of
7 (12%)
Higher education Employed
Study characteristics
In total, 85 women were asked to participate; 14 did not answer the questionnaires (response rate 83.5%), eight were not diagnosed with BD and a further two did not fully complete the questionnaires, thus leaving 61 participants (72% included). As seen from Table 1, the participants were characterised by being young, single without children, heterosexual, well-educated and unemployed. The majority were non-smokers and overweight to obese (BMI > 25). Almost all were prescribed medication, especially mood stabilisers (mean number of medication: 2.2), and half were in remission. Women with BD and BMI > 25 were not prescribed more types of medication (mean 2.1) than those with BMI 5. Major Depression Inventory (MDI) number of patients with current depression defined as a score ≥26 (moderate/ severe). Remission defined as ASRM scores
